‘Precarious (Bio)ethics: Research on Poisoning Patients in Sri Lanka’
On 9 May 2013, Salla Sariola, from ETHOX, gave a fascinating talk at the St Cross Ethics Seminar, based on work done collaboratively with Bob Simpson (Durham). The presentation focused on the large number of self-poisonings which have been taking place in Sri Lanka, often using lethal agricultural pesticides and herbicides unavailable in many developed countries. This presentation is now available as a podcast at the bottom right of the Oxford Uehiro Centre main webpage. Continue reading
Non-consensual testing after needlestick injury: A legal and ethical drama
By Charles Foster and Jonathan Herring
Scene 1: An Intensive Care Unit
Like many patients in ICU, X is incapacitous. He also needs a lot of care. Much of that care involves needles. Late at night, tired and harassed, Nurse Y is trying to give X an intravenous injection. As happens very commonly, she sticks herself with the needle.
Nurse Y is worried sick. Perhaps she will catch HIV, hepatitis, or some other serious blood-borne infection? She goes tearfully to the Consultant in charge.
‘Don’t worry’, he says. ‘We’ll start you on the regular post-exposure prophylaxis. But to be even safer, we’ll test some of X’s blood for the common infections. I doubt he’ll be positive, but if he is, we’ll start you straight away on the necessary treatment. We needn’t take any more blood: there are plenty of samples already available.’
A sample of blood is submitted for analysis. Continue reading
The Cultural Cost of Placebo
A recent poll says that nearly all General Practitioners in the UK have given placebos to at least one of their patients.
The story can be seen here: http://www.bbc.co.uk/news/health-21834440
Everyone loves placebos. If you are a scientist, placebo shows an incredible feat of the human body, and interesting interactions between our psychology and the biology that underlies it. A doctor can rest assured that placebos won’t cause a chain of undesirable reactions in their patients, while still helping them. Even a new age pro-herbal unscientific mind favours placebo, placebos not only aren’t the allopathic evil kind of substance, but with sufficient distortion of argument, placebos can be taken as an argument in favour of whichever branch of neo-medicine that particular mind would like to enforce. So everyone loves placebo, and placebo helps everyone.
Or does it? Here I’ll outline some of the reasons we should be wary of placebo effects, and sketch some cultural costs that are being unconsciously left under the rug by the placebo enthusiasm in which we, or at least General Practitioners, find themselves.
Reason 1) Placebo doesn’t mean what we think it means.
Under experimental conditions, placebos are supposed to be inert to the body. Very few substances are actually as inert as would be desirable, and many times we would find outrageous that substance X was considered placebo. A striking example comes from Beatrice Golomb’s short essay on The Dece(i)bo Effect, where she mentions two studies which assessed the effects of corn-oil and olive-oil in patients who needed to lower their cholesterol. It seems a promising avenue of research until you discover that the olive-oil and the corn-oil were not the target of the study, which was a cholesterol-lowering drug, they were the placebos. The first cultural cost that placebos pay is a labeling cost, once labeled, we lose track of the information of what they contained when studied in the first place.
Reason 2)Placebos don’t function as broadly as we think. Or would like to think.
Placebos are good for pain and anxiety, in the short term. Systematic reviews of general studies of placebo, on the other hand, shows very mild to no effects from placebo. As seen here. The second cultural cost that placebos pay is the cost of being likable, and therefore, less amenable to accurate scrutiny beneath the excitement field. As is widely known, if an idea, meme, memeplex (group of annexed memes) or cultural item is the kind of thing that people just like to believe, it is extremely hard to eliminate it from culture. Placebo is a nice idea, and because of that, it is kept in a safer haven than it should, given how many lives it affects.
Reason 3)Placebos are mysterious, and mysteries are contagious
It is incredible that our minds are able to influence the body in the way they do (irrespective of one’s hardcore eliminative monism or Cartesian dualism). Even if the effects are mild, and more constrained than we think, they are still, in some sense, fantastic, belonging to a world of fantasy. To a mind with inclinations for Skyhook type explanations, they open the gate which parts the world of science from the world of fantasy. Doctors are not immune to aspiring that the world be magical and mysterious, in fact, given their high level of education in scientific matters, if any strong innate or childhood force compels them to look for mysteries and Skyhooks, then once the gate is open the diffusion of memes from one side to the other is likely to be uncanny. And here lies the most dangerous cultural cost of placebos. Placebos open the gate for Skyhooks and mysteries in the minds of those on whom our lives depend. A well educated doctor has to go through a painstaking amount of cognitive dissonance if she is to enforce homeopathic treatment while knowing that nothing she was told while learning the profession indicates that it makes sense. But if there is this other mysterious thing that is well accepted and highly regarded among her peers, well, then the fact that we don’t know how it works should not be a decisive factor against homeopathy, right?
Reason 4) Placebos permit a diminished sense of responsibility by twisting psychological knobs
When administering a placebo, a doctor has more reason to sleep well knowing that he didn’t (really) act in relation to a patient while still helping than if he had (more) actively selected a medication which could have varied adverse effects for the patient, and legal consequences for the doctor. More than that, it permits the doctor to hold himself responsible only in case of success, which is an emotionally comforting position to be in. By psychologically thinking it is less of a directed action to administer placebo, the doctor can ease his sense of responsibility by believing that it was not so much his decision that played a role. Even if in the real world he can be indicted for giving placebo in a condition in which it was wrong to do so, at the decision moment the major players are his self image and internal representation of the event, and these are likely to prefer a story in which he bears no responsibility, except, ironically, the responsibility for infusing the sugar pill with the magical quality that will aid the one in need.
There are good reasons to administer placebos under many circumstances, and the claim here is not that 97.5% of General Practitioners are doing wrong. Instead, it is a call for a sober assessment of which exactly are the circumstances in which placebos ought to be administered. For one thing, in the cases in which placebos are effective, their effectiveness depends on patients actually believing their effectiveness, and for this very reason, it would be a great loss if they became ubiquitous enough that patients stopped believing their effectiveness.
Many cultural items pay the same cultural costs as placebos, being likable, permitting ease of conscience, having ill-defined conceptual borders, and annexing themselves with mysteries are memetic strategies familiar to researchers of cultural evolution, and the items that use those pernicious strategies frequently escape our sight, where I think placebos should be attentively kept.
Practical Ethics and Philosophy
It is now quite common to draw distinctions between three types of philosophical ethics. Practical ethics is meant to concern substantive moral issues facing many of us each day, such as abortion or climate change. Continue reading
Too long in gestating: an overdue inquiry into the Abortion Act
Whatever your view of abortion, there are too many abortions, and too many of them are too late. Even abortion’s fiercest advocates don’t pretend that it’s a Good Thing – just the lesser of two evils.
In 2010 there were 189,574 abortions in England and Wales – an 8% increase in a decade. The tightly policed regime envisaged in 1967, when the Act became law, hasn’t existed for ages, if indeed it ever did. There is abortion on demand, whatever the statute book says.
1967 was a long time ago. There have been many medical advances and societal changes since then. It’s time to take stock of the Act.
That’s what a recently announced cross-party commission, to be chaired by Fiona Bruce MP, will do.
It will focus, rightly, on two issues: medical advances and attitudes to discrimination. Continue reading
Whom Should We Refuse to Treat? Pregnant Rape Victims? Surrogates?
By Lachlan de Crespigny and Julian Savulescu
An emergency centre doctor working in Germany has claimed 2 nearby catholic hospitals refused to accept a rape victim who needed treatment, in case she was pregnant . This was allegedly in line with their ethics committee’s policy to refuse to examine sexual assault victims in an effort to avoid future treatments such as the morning after pill coming into conflict with the hospital’s catholic ethos. The hospitals claim this was a misunderstanding and await an internal inquiry.
The Catholic Church does not support abortion and includes the morning after pill as an abortifacient. It is in violation of Catholic (ethical) standards. The doctor making the claims says that Cologne’s Cardinal Meisner had been consulted.
The Catholic Church insists life must be protected with the utmost care from the moment of conception. From the first moment of his or her existence, a human being must be recognized as having the rights of a person. But in this case, they did not only deny the rape victim access to legal contraceptives, they refused to treat or examine her in any way for any of the resulting injuries of the rape. They did not treat her in her hour of need as a person who deserved the utmost care.
Where are my smart genes? Searching for intelligence in our DNA
Reproductive technologies such as in-vitro fertilization (IVF) and preimplantation genetic diagnosis (PGD) mean it is currently possible for parents to create a range of embryos and make decisions about which to implant on the basis of their genetic makeup. One interesting possibility is that we will soon be able to use such technologies to influence the intelligence of our future children. It is known that intelligence has at least a moderately important genetic component. Identical twins are significantly more similar in intelligence than dizygotic twins, who are in turn significantly more similar than adopted siblings raised together. In fact, a range of studies indicate that the heritability of intelligence is approximately 0.7, which is only slightly lower than the heritability of height. This means that 70% of the variation we observe in intelligence is due to genetic factors. Once we can identify the genes which explain this variation it will be relatively simple to test embryos for them, meaning it will be technically possible for parents to select embryos on the basis of their likely intelligence.
However scientists are finding it surprisingly difficult to locate the specific genes which affect intelligence. Continue reading
Abortion and the cognitively impaired mother
It will be interesting to watch the reception of a recent Court of Protection case, as yet unreported, in which a woman with profound learning difficulties was found to have capacity to decide not to terminate her pregnancy.
As so often, the case decided nothing new. But it is a timely reminder of the trite but often overlooked principle that capacity is not an all or nothing thing. The question: ‘Does she have capacity?’ is always dangerously incomplete. The correct question is always ‘Does she have capacity to decide X?’
There was no doubt that she did not have capacity to manage many aspects of her affairs. She was in the bottom 1% of the population so far as intellectual function was concerned. Deputies were appropriately appointed. But, so far as the continuation of her pregnancy was concerned, so what?
It was decided as a matter of fact that she had capacity to decide whether or not to continue with, or to terminate, the pregnancy. And that meant that the Court of Protection had no jurisdiction to decide the matter. No best interests determination could lawfully be made. Continue reading
The Best Practical Ethics Books of the Year…
By the editors of the Practical Ethics blog.
What is the best practical ethics book you read this year, and what is so good about it (in 1-3 sentences)?
We asked this question to our colleagues at the Oxford Uehiro Centre for Practical Ethics. To our surprise, not a single title received multiple votes. This perhaps indicates that so many good books in the field appeared in the last couple of years, or perhaps a different explanation is due. Either way, below is the list of the recent titles we found excellent:
The Ends of Harm: The Moral Foundations of Criminal Law by Victor Tadros
‘In this book, Tadros provides a highly engaging non-consequentialist account of the permissible harming of others. It is an important and illuminating work containing a number of original insights’. – David Birks
The Ethics of Transplants: Why Careless Thought Costs Lives by Janet Radcliffe Richards
‘I give this out to people as a paradigm example of how to do good practical philosophy, especially in medical ethics. Janet dismembers bad arguments, like a pathologist dissecting a corpse riddled with metastatic cancer, and reveals the diagnosis, chapter after chapter. It is a fine example in the now neglected method of giving sound arguments, and exposing invalid ones. It is unabashedly pre-postmodernist and, as such, is intelligible and useful to any thoughtful person, specialist or non-specialist.– Julian Savulescu
Moralizing Technology: Understanding and Designing the Morality of Things by Peter-Paul Verbeek
‘A thought-provoking account of human-technology relation that calls for a new understanding of and method for ethics in our technological age. This book will surely give you some food for thought. Perhaps, it will even change the way you understand the technologies around you’. – Pak-Hang Wong
Philosophy and the Environment ed. by Anthony O’Hear
‘Philosophy and the Environment contains several excellent papers, including an outstanding piece by David Wiggins, which is both ethical and practical’. – Roger Crisp
The Prison Officer by Alison Liebling, David Price, and Guy Shefer
‘Most of us never face extreme violence, aggression, corruption and despair, let alone need to make good, daily decisions about how to manage it effectively and with moral decency. Prison officers do. This book explores the psychology of prison officers and their relationships with prisoners, revealing what it is to do this demanding job well and carve morality out of the chaos often found within prisons’. – Hannah Pickard
The Righteous Mind: Why Good People Are Divided by Politics and Religion by Jonathan Haidt
‘The Righteous Mind synthesises Haidt’s influential work on different aspects of moral psychology, to create a unified vision of the field, and it is having significant influence accross a variety of academic disciplines’. – Stephen Clark
Skepticism and Freedom: A Modern Case for Classical Liberalism by Richard A. Epstein
‘An interesting consequentialist defence of classical liberalism, limited government and free markets by an eminent academic lawyer. Philosophers may think some of the philosophical arguments go by rather quickly, but this is to miss the peculiar virtue of the book. His knowlege of the way law has worked in practice and the commonalities of law across culture and history fills out the defence with the kind of important and illuminating facts that philosophers rarely know’. – Nicholas Shackel
‘The Spirit of Compromise skilfully combines normative reasoning with empirical analysis to provide concrete suggestions to correct some of the most serious deficiencies in contemporary democratic politics. It brilliantly shows how the “policy implications” of normative theory can be more than a polite gesture towards funding bodies’. – Kei Hiruta
Thinking, Fast and Slow by Daniel Kahneman
‘A nice summary of the evidence he’s compiled during the course of his brilliant career into the scary levels of human irrationality’. – David Edmonds
Why Some Things Should Not Be for Sale: The Moral Limits of Markets by Debra Satz
‘It draws on philosophy, economics, and anthropology to present a sophisticated and nuanced appraisal of the moral consequences of markets in human organs, sex and other actual or potential commodities. In doing so, it moves the debate about markets beyond the standard trite claims about efficiency, equality, or human dignity’. – Simon Rippon
‘1493 is a beautifully written and deeply insightful exploration of how hard it is (and has always been) to anticipate the human consequences of globalization’. – Regina Rini
Is your favourite recent title listed above, or do you have other suggestions? Please reply below to share with us the practical ethics book you found most interesting this year!
When to eat the marshmallow: new perspectives on impulse control
In light of the fact that many readers will have an assortment of Christmas treats tempting them, I thought a post on impulse control would be timely.
In the now paradigmatic Stanford marshmallow experiment, children were given an option – one marshmallow which they could have immediately, or two marshmallows, provided they could wait 15 minutes. This option presents a problem of sorts. Is it better to have a small reward immediately, or a larger one after some delay? Common sense says that waiting is the better option. Doubling your reward whilst only paying a marginal cost of your time seems like the rational thing to do. Children who fail to wait are, therefore, seen as succumbing to temptation. A deficiency in self control leads them to make a poor decision. Continue reading
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